Dementia Services Information and Development Centre

Integrated Pathways of Dementia Care in Action

HSE and Genio Dementia Briefing 14th December 2016

This half-day meeting, held in the Ashling Hotel, Dublin aimed to highlight the progress and pitfalls to date of the three Genio funded hospital projects. The three hospital sites - St James's Hospital (Dublin), Mercy University Hospital (Cork) and Connolly Hospital (Dublin) - have been charged with "developing integrated care pathways for people living with dementia to support planned and appropriate access to acute services and to improve their experience while in hospital."

Following an initial welcome from Madeleine Clarke, Executive Director of Genio, the morning was formally introduced by the HSE's Head of Operations and Service Improvement for Older People, Michael Fitzgerald. An overview of the programme was succinctly given by Dr Fiona Keogh and initial findings were presented by Dr Anne Marie Brady from TCD, head of Genio's official evaluation team for the three projects. Interesting findings from the initial baseline evaluation included the disparity between the hospitals on the median length of stay for people with dementia. St James's had the longest length of stay and also the highest median cost per case whilst Mercy University Hospital had the lowest median cost and Connolly the lowest median length of stay. All three hospitals managed to discharge more than 40% of their patients with dementia back to their own homes and all discharged between a quarter and a third of their patients to long term care. We look forward to more detail emerging from the evaluation over the coming months.

The second half of the meeting, where the three hospitals presented an overview of their projects to date, was preceeded by a moving talk from Hazel Luskin Glennon who had cared for her husband until his death. Hazel had always wanted to care for Brendan at home but the system as it currently stands did not facilitate her to do this. Instead it pushed her towards hospital and nursing home care with, she argued, increased costs to the state and worse outcomes for Brendan. She implored the decision-makers to support carers to care for their loved ones at home where possible.
Professor Brian Lawlor provided the update on St James's Hospital's Dempath project concentrating on its three main components - education, environment and the integrated care pathway (ICP). Significant achievements have been made such as 88% of patient facing staff having received dementia awareness training and work having started on an on-line training tool. Two bed bays in the Emergency Department have been redesigned with people with dementia and/or delirium in mind and Dempath had a significant input into the new signage in the MISA building. The development of an effective ICP is a major challenge and work to date has improved the identification of people with dementia via the adoption of assessment tools like the 4AT. It has also improved the information going back out to the community with cognitive impairment and delirium being highlighted on the discharge letter.
Dr Suzanne Timmons presented the interim report on the Cork-IDEAS project based in the Mercy University Hospital. This project also targets the three areas of training and education, the environment and an ICP. They have delivered over 475 staff awareness sessions and have dementia awareness integrated into UCC's pre-intern training sessions. Within the community setting they have held 176 awareness sessions and plan to develop a dementia education and resource booklet. Another exciting prospect is the link-up with the PREPARED project which provides a new GP education module for the doctors working in the community. Environmental changes have included the re-design of a hospital ward to make it more dementia friendly, the adaption of a bed bay in ED, improving the colour contrast in an adapted toilet and improved signage and wayfinding features.
The development of an ICP for people with dementia has led the Cork-IDEAS project to also adopt the 4AT assessment tool to identify those patients with dementia and/or delirium. To date over 400 patients have been assessed in this way. The integrated care pathway extends out into the community via supported discharge and to try and avoid hospital admission. Much of this is centred around a Memory Intervention and Support Clinic. This encompasses walk-in community services such as an Alzheimer Cafe, professional-led supports such as a Memory Gym and Mindfulness programme as well as a multi-disciplinary team for the management of complex cases.

Dr Siobhan Kennelly presented on the Connolly Hospital Dementia Pathways Project. The Connolly project is based around four key headings: Integration, Education, Person-centred care and Environment. The integration element is delivered with two key posts - a full-time clinical nurse lead based in the hospital and a half-time public health nurse post in the community. These are supported by an existing geriatrician and clinical case managers for older people. A Memory Assessment and Support (MAS) Clinic provides a diagnostic and follow-on support for those receiving a new diagnosis of dementia and, since February 2016 they have offered an urgent referral system, which, like the other two projects, relies on the early identification of delirium/dementia. Regular patient (or family) contact with the Clinical Nurse Specialist is seen as key to the success of the MAS Clinic and a way of avoiding admission to acute hospital. The introduction of the 'Personal Passport' - a non-medical document that acknowledges the individuality of the patient is felt by both staff and families to improve the person-centred nature of the care in an acute setting.  Connolly's educational approach has embraced short but effective training situated on the ward based at the 'whiteboard'. They have also conducted one hour dementia awareness education sessions and utilised DCU's Dementia Elevator training and their Dementia Champions course. One of their most novel approaches has been the introduction of a monthly telementoring service for local nursing homes. This uses facilitated video conferencing to provide a forum for the nursing homes to discuss patients directly with professionals in Connolly Hospital.

The meeting ended with an informative 'Question and Answer' session with the three clinicians.  This was a well attended meeting that gave the three hospitals an opportunity to update the audience on their projects and how their initiatives are impacting on patient care and treatment within the hospital and in the wider community.

Please click here for a copy of the presentations from the meeting